JOB DESCRIPTION SUMMARY:

The PFS Coding Representative must have knowledge of multiple payer’s application, billing and/or collection process and must have extensive working knowledge of insurance regulations, managed care practices, regulatory agencies and alternative funding sources, as well as the reimbursement and regulatory environment and have extensive knowledge of accounting, healthcare, general office procedures, standard PC word processing, payer website navigation, and spreadsheet applications. This position is responsible for supporting management and other Patient Financial Services (PFS) Department personnel in the billing and collection of accounts receivable for all patient accounts, cash application and reconciliation, and/or resolving customer service issues.

EDUCATION:

• Skill and proficiency in diagnosis and procedure coding and other principles, concepts, techniques of Health Information Management as normally acquired through the completion of an accredited AHIMA or AAPC certification program.

EXPERIENCE:

• 2-3 years of direct coding experience required.
• A CPC, CCA, CCS, CCS-P, RHIT, or RHIA must have 3-5 years of direct coding experience preferred.
• Experience with electronic medical records preferred.
• Revenue Cycle experience such as Patient Access Services, Revenue Integrity, Health Information Management, Patient Financial Services, Compliance, or related departments or functional areas preferred.

Leadership

• Contributes to the development of standard operating procedures and/or job aides for the PFS Department.
• Maintains professional competency, according to department policies, procedures and protocols.
• Assumes responsibility for professional growth and development.
• Reviews changes in processes or payer requirements; communicates shifts in healthcare trends, rules and regulation changes.
• Leads cross-functional departmental committees or special task units and/or action teams as assigned.
• Works with other departments as needed to appropriately contribute to account resolution or effective receivables management.
• Gathers data, summarizes and prepares reports for management and completes special projects as assigned.
• Adheres to established departmental policies for attendance, punctuality, procedures and safety.
• Works to ensure full utilization of technology and processes to create an efficient and effective department.

• With the assistance of involved departments, develops improved procedures to facilitate accurate billing and documentation.Participates in the PFS Department’s management meetings and works with the PFS Department’s management team to act as the coding support for each functional area.

Process

• Demonstrates proficiency and knowledge of the following functions: Billing; Accounts Receivable Follow-up; Payment Discrepancy (Denials / Underpayments); Payment Posting and Cash Reconciliation; Credit / Refunds; Self-Pay Processing (including qualifying accounts for charity care / bad debt); Customer Service.
• Identifies or reviews problem accounts and assists the other PFS Department functional areas to work those problem accounts toward timely resolution.
• Works with multiple payers’ provider representatives on issue resolution including claim resolution projects and process enhancements.
• Oversees the handling of “special handling” requests, complaints or inquiries regarding patient accounts to ensure correct and satisfactory resolution.
• Works billing edits from the claims management system utilizing coding knowledge and correct error edits by appropriately applying modifiers, verifying or correcting charges, and/or correcting coding issues.
• Audits charges for the PFS Department upon request to verify charge posting related to payer denials, patient grievances, etc.
• Works with other Revenue Cycle departments, the Information Systems Department, and clinical revenue-producing departments to resolve charging issues.
• Works with clinical and other revenue-producing departments to correct and post charges on accounts that have already been final billed.
• Assists with the interpretation and research of denied charges and claims from third-party payers.
• Uses coding knowledge to prepare appeals to denied charges and claims or otherwise supports the activity of the PFS Denials Management Unit.
• Reviews electronic medical records and identifies all treated diagnoses and significant procedures performed.
• Sequences diagnoses and procedures according to coding guidelines.
• Uses encoders and other electronic tools to assist in the assignment of diagnosis and procedure codes, modifiers, Diagnosis Related Group codes, Ambulatory payment Classification codes, and other related tasks.
• Utilizes online coding references, National and Local Coverage Determinations, and other payer guidelines to ensure appropriate code assignment for appropriate billing compliance.

Customer Service

• Assists the PFS Customer Service area in providing customer service regarding billing questions that require coding knowledge.

Communication

• Works closely and constantly with the Coding Managers of the Health Information Management Department to ensure all coding for all patient accounts is accurate, compliant, and consistent with all regulations and coding guidelines.
• Coordinates communication with other departments, sites, and patient access to reduce recurring errors and denials and establish appropriate prevention measures.
• Represents the PFS Department by participating in standing meetings, committees, and other ad-hoc meetings as requested or required. Ensures that all written responses are clearly and professionally communicated.

Other

• Maintains current certification as either a Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC) or a Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-Based (CCS-P), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) through the American Health Information Management Association (AHIMA). Takes personal accountability for professional growth and development. Performs related responsibilities as required or directed.